Specialist Medical Camps - An Ethos and Ethical Perspective - Mike Smith FRCS

A mother pacifies her baby while its ear is cleaned

Personal background
About 10 years full time work in Nepal, since first tour in 1980.
Running over 40 ear surgical camps, and 2 ENT camps in district hospitals and health posts in Nepal.
Working in Western Regional Hospital, Nepal at tertiary level.
Receiving one ear surgical and two eye camps by other teams.
Receiving visiting foreign surgeons, working with them and following up their results.
Teaching Otology in India and Uganda as well as on sitting on humanitarian panels at international conferences.

Help those with poor access to health care, directly or through teaching others. Compassion.
Keep perspective on needs in the community, not just what reaches the referral centre.
Visit the periphery, work there and understand the situation better.
Teach where the trainees work, on their territory, only then can treatments be planned in an appropriate way.
Don’t call local staff away unnecessarily from where they are needed, but take training to them and learn from them, it will be a more suitable level of teaching, as we see what is possible and works well at the local level. Observe and listen, what facilities do they have, what are the problems?

Aims of camps / visits
Providing a service to patients and also taking opportunities to train staff - no dichotomy, not mutually exclusive.

1. Service to patients; caring, helping, meeting some needs.
2. Service to hospital or local health facilities; improve standing/status of hospital as a service to the community- a place where things happen; improve future service through training; earn registration fees for the hospital; get hospital equipment operational.
3. Part of a strategy, not a one off; technical support and repeat visits with changing emphases according to local needs, which may change at each visit.
4. Equipment supply and maintenance, repair or donate necessary items, improve basic facilities wherever possible. Be guests, leaving facilities better after the visit than before. Need to create a positive attitude with local staff. Be part of an integrated programme of health service / hospital partnership / support. Only give materially when local staffs demonstrate they can use, use safely, appreciate and care for donated equipment.
5. Training commitment, to various levels of staff; planned and appropriate. Prepare teaching programmes, teaching materials. Combined with provision of medical equipment where necessary; of an appropriate, maintainable type. When possible give certificates of training, as a benefit to trainees. Identify personnel with potential for further training at subsequent visits. When possible integrate with local training programmes and work with trainers. Teach what they want to know, they have the best idea of their needs.
6. Information transfer. Health education of patients, community, Passing on of knowledge about diagnosis and treatment to other health service providers such as medical shops by giving written results of examination, diagnosis and treatment to patient. Informing staff about appropriate referrals and places where treatment is available.
7. Links with staff who are posted / rotated around primary, secondary and tertiary centres. Maintain and make new contacts, relationships.
8. Discover needs, publish results of visits, numbers of patients with various problems, aid health service planning and those who follow. Epidemiology, variations in disease patterns in different geographical and racial groups. Use results to modify ensuing visits to same or other places. Publicise needs, represent the needy in health political arena.

1. Creating or leaving behind problems for local staff.
• Onus is on visitor to arrange adequate follow up and contacts.
• Plan for care of any complications; arrange transfer to a referral centre when needed.
• Keep and leave place tidy
• Cover any costs which may fall on receiving hospital
• Not all exigencies can be covered, but must learn from experience and modify visits accordingly, discuss methodology with others in the country and elsewhere with experience of medical camps.
2. Wrong aims.
• Self promotion, attracting patients to own clinic etc.
• Political gain, publicity for self.
• Personal enjoyment, holiday, merit.
3. Provide what you say you will, don’t raise unrealistic expectations. Prescribe only medicines which are essential, evidence based and cost effective, and locally available or take them with you.
4. Plan well, take necessary equipment and backups.
5. Do not waste money/resources of poor people with inadequate or inappropriate treatments
6. Do not try to do too much, plan well what is possible in a camp/ visit in your speciality.
7. Identify clear targets, not too many doctors or specialties,
8. Do not swamp local facilities and stop their normal operation, leaving the perception that local staff cannot provide these facilities and it would be better if patients went elsewhere, instead of a perception that local and visiting staff are equal colleagues who work together to help the patient.
9. Beware inexperienced foreign staff visiting on short visits, may not treat appropriately due to poor knowledge of local conditions, climate etc.
10. There is a risk that treatment may be poor, especially when working away from visitor’s base hospital, with different equipment and surroundings. Must have staff with local experience present or set small targets until experience achieved. Do not undertake procedures that can be better done elsewhere by someone else who is accessible. Do not underestimate their skills.

Always leave something positive behind. Equipment or repaired facilities are valuable but training can be more lasting.
• plan in advance.
• take teaching materials
• identify clearly the group you want to teach, e.g. HA, CMA; health education of patients.
• call in appropriate staff in advance.
• can use service/examination/treatment times as a vehicle for teaching.
• do not leave unhappy staff, grumbling about the problems the camp has caused them behind you, They will soon forget any benefit but not the difficulties unless they are given priority in planning.
• the type of training will vary with target group/diseases/local requests.
• aim is not to leave people feeling you are very clever and they could never do any of the treatment themselves. Must give them achievable targets of learning, however simple, and the confidence to continue after you leave. More than one visit may be needed.

Should patients pay?
In my view yes, because;
• people tend to value things they pay for, and may be suspicious of what they do not. Self respect.
• health care costs money, it is not sustainable in the long term as charity. The money has to come from somewhere, either
- themselves
- a wider community; in practice the state or commerce, through taxes or through health insurance.
If patients are to cover the costs in part or in whole then we have a duty to prescribe responsibly. Camps are normally aimed at the poorer patients and we should develop a pharmacopoeia which is low cost and safe for our area of work.
Costs should be minimised without compromising good medical practice.
A poor fund should be set up to cover the truly destitute. The funding of this has to be worked out.

Different specialities have to make value judgments about what is appropriate, successful, and achievable in the circumstances of a camp type visit.
Some disciplines can be taught to local staff with little difficulty e.g. dermatology.
Other disciplines can be taught and practiced in a district hospital after provision of some equipment e.g. dental extraction.
Others are unlikely to be available in DGHs in the near future, such as my own specialty of otology. Then the visit takes on a more service role. However whilst complex surgery may be done by the visitor with his equipment and experience, diagnosis and non-surgical treatment of common conditions can be taught to paramedicals at the same time.

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